UTI inElderly and

Systemic Disease

ewha univ. hosp.

shim, bongsuk

1How to Manage UTI in the Elderly

Aging & Infection

UTI in the Elderly

Recurrent UTI

Asymptomatic Bacteriuria

CAUTI

Impact of Aging on Infections Impact of Aging on Infections

Aging increase risks of infection

Immune changes drops with age

Organ changes skin ; decrease protection bladder ; changes to increase UTIs

Age-related diseases cancer, diabetes, dementia, voiding dysfunction, etc

Physiologic changes hospitalized, institutionalization, medical procedures

Department visits by ElderlyDepartment visits by Elderly

Drach GW. AUA Update Series Vol 24 Lesson 33 2005

Infectious Disease in ElderlyInfectious Disease in Elderly

Yoshikawa TT. J Infect Dis 1997

UTI in the elderlyUTI in the elderly

extremely commonmost frequent infection among infectious

diseases in the elderlyrisk factors for developing UTIs

dementia, incontinence, decreased mobility

asymptomatic bacteriuria is common 15-30% in men 25-50% in women

Factors Associated with UTIFactors Associated with UTI

bothmen women

BPHProstate CaProstate stoneUrethral strictureEtc.

Coexisting diseasesDiabetes mellitusCerebrovascular accidentsDementiaIncreased hospitalizationsInstrumentationUrinary cathetersAlterations of immunity

Changes in bladderIntroital G(-) bacteria

colonization ↑Vaginal glycogen ↓

Vaginal pH ↑

Kunin CM. 1987

Underlying Dis. in complicated UTIUnderlying Dis. in complicated UTI

Causative Organisms of UTICausative Organisms of UTI

Escherichia coli most common, 60~70%, but relatively low rate

Proteus mirabilisKlebsiella pneumoniaeenterococci

more common than younger people

Pseudomonas aeruginosa leukemia, aplastic anemia, after GI tract manipulation

Staphylococcus rarely in elderly

Melani PN. Clin Geriatr 2005

classic symptoms dysuria, frequency, urgency absent, masked or difficult to assess only 20% with new urinary symptoms

upper UTI confusion (delirium), lethargy, agitation, collapse 15%, no fever and no leukocytosis deteriorate more rapidly from infection bacteremic UTI in the elderly

often present respiratory symptoms, treated as ‘Pneumonia’

Clinical PresentationClinical Presentation

Barkham, et al. Age & Ageing 1996

DiagnosisDiagnosis

historyphysical examinationlaboratories

urinalysis ; 5-10 WBC/HPF

urine culture & sensitivities ; >105 CFU/mL

may diagnose acute uncomplicated cystitis based on history, P/E, and U/A alone, no need for culture to treat

Therapy with AntibioticsTherapy with Antibiotics

3-day course for simple acute cystitis

7-day course complicated by hospitalization instrumentation of the urinary tract diabetes immunosuppression failure of previous therapy more than three infections in the previous year symptoms lasting over 7 days

Hooton TM. Med Clin North Am 1991Stamm WE. N Engl J Med 1993

Antibiotics for UTIAntibiotics for UTI

Adverse Effects of AntibioticsAdverse Effects of Antibiotics

Melani PN. Clin Geriatr 2005

Acute Pyelonephritis (1)Acute Pyelonephritis (1)

atypical clinical presentation fever, confusion, lethargy, nausea and vomiting often of little help in the diagnosis 15%, no fever or no leukocytosis

Laboratories three sets of blood cultures and one urine culture

Radiographic studies for urinary tract obstructive uropathy, calculous disease or abscess IVP, ultrasound or CT

Acute Pyelonephritis (2)Acute Pyelonephritis (2)

Treatments hospitalization : bed rest, adequate hydration,

symptomatic care

aminoglycoside (amikacin, gentamicin, tobramycin) + cephalosporin IV for 5~7 days

oral antibiotics for more 2 weeks

no response after 2-3 days : re-evaluation

Follow-up repeat UC at least 6 months after treatment

Preventing Recurrent UTI Preventing Recurrent UTI

Increased fluid intake no evidence, but it may be helpful

Antibiotic prophylaxis useful if >3 symptomatic UTIs/year risk of resistant organisms

Topical estrogen improves atrophic vaginitis encourages lactobacilli growth

Cranberry juice

Asymptomatic BacteriuriaAsymptomatic Bacteriuria

> 105 CFU/mL on 2 consecutive occasions no UTI symptomsmore common

in institutionalized or hospitalized patients

prevalence

Abrutyn E, et al. J Am Geriatr Soc 1988

Men Women

40 ~ 60 y.o 0.1% 5.0%

65~80

y.o

ambulatory population 6% 18%

nursing homes 23%

hospitals 32%

over 80 y.o 21% 25~50%

Clinical Significance of Asymptomatic BacteriuriaClinical Significance of Asymptomatic Bacteriuria

in the past increased mortality routine treatment Nordenstam GR, et al. N Engl J Med 1986

no direct causal association with mortalityrare proceeding to symptomatic UTInot recommend routine screening and

treatment Baldassarre JS. Med Clin North Am 1991

Kunin CM, et al. Am J Epidemiol 1992

No Screening for or Treatment of Asymptomatic BacteriuriaNo Screening for or Treatment of Asymptomatic Bacteriuria

pre-menopausal, non-pregnant women

diabetic women

older persons living in community

elderly institutionalized subjects

persons with spinal cord injury

catheterized patients while the catheter remains in situ

Boscia JA, et al. JAMA 1987Nicolle LE, et al. Am J Med 1987

Abrutyn E, et al. J Am Geriatr Soc 1988

Screening for or Treatment of Asymptomatic BacteriuriaScreening for or Treatment of Asymptomatic Bacteriuria

pregnant women

suspicious obstructive uropathy

before TURP

before urological interventions

before prosthetic device hip or cardiac valve

Nicolle LE, et al. Am J Med 1987Abrutyn E, et al. Ann Intern Med 1994

Catheter associated UTICatheter associated UTI

incidence 27% under 65, 52% over 65 10-15% of hospitalized patients with indwelling

catheter develop bacteriuria 3-5% per day of catheterization one-time catheterization ; 2% bacteriuria

gram(-) bacteremia most significant complication of CAUTI

greater antimicrobial resistanceabsence of symptoms no treatment

Garibaldi RA. N Engl J Med 1981, Gleckman R. J Urol 1982

세상에서 제일 무서운 여자는 ?세상에서 제일 무서운 여자는 ?4,50 대 남자들에게 물었습니다 .4,50 대 남자들에게 물었습니다 .바로 호랑이 마눌님 입니다 .바로 호랑이 마눌님 입니다 .

. 2How to Manage UTI in the Diabetes

DM and infection

Immune System in DM

UTI in the Diabetes

Emphysematous Pyelonephritis

Common UTIs in DM

Infection and DMInfection and DM

higher of incidence of infection complication & death - more frequent specific immunologic defects the risk factors of infection and resulting

complication duration of illness severity of non-infectious complications concurrent illnesses level of glucose control degree of medical supervision

Seymour A. Med J Aust 1963Robbins SL. N Engl J Med 1994

Pathogenesis of Renal Failure in DMPathogenesis of Renal Failure in DM

Diabetes and the Immune System (1)Diabetes and the Immune System (1)

function of PMN leukocytes depressed chemotactic index – diminished response diminished phagocytosis diminished bactericidal activity

monocyte function decreased circulating monocytes impaired monocyte chemotaxis

Mowat AG. N Engl J Med 1971Molenaar DM. Diabetes 1976

Geisler G. Acta Pathol Microbiol Immunol Scand 1982Hill HR. Clin Immunol 1983

Diabetes and the Immune System (2)Diabetes and the Immune System (2)

cell-mediated immunity decreased the transformation of lymphocytes decreased mitogenic response diminished release of migration-inhibition factor by T

lymphocytes

miscellaneous factors abnormalities in the microvascular circulation

decrease tissue perfusion

impair response to therapy

MacCuish AC. Diabetes 1974 Casey JI. J Infect Dis 1987

McMillan DE. Mayo Clin Proc 1988

Infectious Diseases in DMInfectious Diseases in DM

Infections strongly associated with diabetes Mucormycosis Malignant external otitis Emphysematous Pyelonephritis Emphysematous Cholecystitis

Infections possibly related to diabetes Urinary tract infections Fungal infections Staphylococcus aureus infections Soft-tissue infections Tuberculosis

UTI in the DiabetesUTI in the Diabetes

UTI more common more serious infections

increased risk of complicated pyelonephritis

asymptomatic bacteriuria is common cleared bacteriuria in short term but did not decrease number of symptomatic

episodes or hospitalizations does not reduce complications in diabetes

Harding, NEJM 2002

Common UTIs in DMCommon UTIs in DM

Emphysematous pyelonephritis Renal or perirenal abscess Papillary necrosis Xanthogranulomatous pyelonephritis Fourniere’s gangrene Staphylococcus bacteremia

Emphysematous Pyelonephritis (1)Emphysematous Pyelonephritis (1)

85-100% of patients ; associated with DM Michaeli J, et al. J Urol 1984

Zebbo A, et al. Urology 1985

10% of patient ; bilateral involvement glucosuria providing a substrate for

production of gas by fermentation

causative organisms E. coli, Klebsiella pneumoniae, Proteus mirabilis,

Enterobacter aurogenes Candida species

Therapy potent antibiotics, for several weeks? relieve any obstruction undertake percutaneous drainage consider nephrectomy if clinical improvement does

not occur

mortality rate medical : 75%, surgical : 23% Lowe FC & Walther JM. Urology 1986

Emphysematous Pyelonephritis (2)Emphysematous Pyelonephritis (2)

Renal Abscess Renal Abscess

twice frequency in DM Saiki J, et al. West J Med 1982

Plevin SN, et al. J Urol 1979

Pathogens E. coli, Klebsiella, Proteus

Treatment antibiotic therapy alone ; resolve prompt drainage ; no clinical improvement within a

few days, large collection, obstructive uropathy open incision and drainage ; no response to closed

drainage

Perinephric Abscess Perinephric Abscess

DM ; major contributing factor in perinephric abscess

14-75% of perinephric abscess ; DM Patterson JE. Infect Dis Clin North Am 1987

no symptoms resolving for pyelonephritis within 4-5 days prompt radiologic evaluation – CT scan

Treatment drainage in combination with a prolonged course of

antibiotics

Renal Papillary Necrosis (1)Renal Papillary Necrosis (1)

Brauner A. Diabetes Res 1987 DM increase risk of renal papillary necrosis patients with proteinuria in DM ; more infected with

P-fimbrated strains of E.coli

suspect of renal papillary necrosis frequent relapsing or difficult-to-eradicate

pyelonephritis fulminant presentation of pyelonephritis,

accompanied by hematuria more than 3 times UTI ; higher risk of papillary

necrosis

30-50% of papillary necrosis ; DM Mujais SK. Semin Nephrol 1984

Treatment eradication of infection ; intensive antibiotics catheter drainage or PCN for obstruction and

pyonephrosis appropriate duration of antibiotics ; not clearly

established nephrectomy

Renal Papillary Necrosis (2)Renal Papillary Necrosis (2)

Fungal Urinary Tract Infection Fungal Urinary Tract Infection

Candida albicans, Candida glabrata Roy JB, et al. Urology 1984

predisposing condition use of antibiotics, indwelling urinary catheter

role of DM not clear precisely

Treatment fluconazole orally

Fournier’s Gangrene Fournier’s Gangrene

subclassification of necrotizing fasciitis around the male genitalia

often in combination with DM, 40% bacteria

a mixture of gram-negative bacteria, anaerobes, streptococci

treatment wide surgical debridment of devitalized tissue

mortality rate 40-50% even with aggressive management